SARS From Behind The Mask

Vincent Lam, National Post
April 19, 2003

I never knew how much I relied upon lip-reading in my job as an emergency physician, until I became unable to see the faces of my patients. For the past two weeks, going to work in a SARS-protected environment has meant spending hours smothered in an N95 mask, wrapped in an isolation gown, wearing eye protection, and gloves. Patients in the emergency department are masked as well, so we peer at each other like disembodied eyes and hairstyles. Suddenly, I cannot understand what anyone is saying. Words are usually obscured by accents and the noise of the emergency department, but now they are also muffled by the mask material itself and I cannot watch people's lips. I now realise how much I need to see the movement of lips to understand speech.

"I see berry berry vizzy," says my patient.

"What?" I say.

"I see fizzy," says my patient.

"You feel dizzy?" I say.

My patient nods, finally.

Already, SARS is becoming a 'new normal' for those of us who continue to work in Toronto hospitals. Many hospital clinics are closed, but for those of us who remain in what are deemed to be essential services, we are becoming accustomed to lining up in a tent in the back of the hospital in order to get into work. All the entrances are sealed except the emergency entrance, where patients pass through a parked TTC bus to be screened, and the back entrance where staff are processed in the tent. There, our temperatures are taken as we file past infection control workers with thermometers. We answer daily questionnaires about our physical condition, whether we have worked at other hospitals, whether we have travelled, and whether we have cared for SARS patients. If we are deemed to be 'clean', we are issued our daily gown and mask, which we must don in order to enter the hospital, and can go in to work. Each day there seem to be different models of masks, and staff members are developing individual preferences regarding masks. All of them are smothering and hot. One of the nurses in the emergency department brought smiley stickers, which could be scratched and sniffed to release a strawberry scent. On that day, we had strawberry smiley stickers on the exhalation ports of the N95 masks.

One of my fellow physicians refused to have a sticker on his mask, saying,

"There's nothing funny about this."

He's right, of course. It's not funny, and we're all scared.

During normal times, the emergency department carries a sense of rough and ready fatalism. Bad things happen, and disaster wheels in - sirens blaring. We jump into the fray, try to save a life, and then the next patient rolls in. Now, we feel that the danger of SARS lurks in our midst, and more than just responding to it, we may become its victims. Many of the SARS cases in Toronto have been amongst health-care workers. Even though SARS patients are isolated from the public, we must continue to care for them. For us, it is not far away. We are comforted by the fact that SARS has reached health care workers only, seemingly, before current infection control measures were undertaken.

It is the unknown which is most sinister. At present, laboratories around the world spend sleepless night trying to isolate the SARS pathogen. The mode of transmission is unclear but our main line of defence, quarantine and isolation, is an effort to break transmission. So, we are fighting an enemy that we cannot see with weapons of unknown effect. What we grasp are the screening questionnaires and treatment protocols which outline who should be suspected of SARS, who should be isolated, who should have the myriad swabs and tests drawn, who should be admitted to hospital, and who should simply be reassured that, as far as we can tell, they do not have SARS.

The protocols have been changing. Before leaving for each shift at the hospital, I check my Email to know if the guidelines are different today. I print out the flow-charts, to see if all the little arrows go to the same boxes they led to on the last flow-chart. Patients that we would have sent home in the first days of the outbreak are now being admitted to hospital. It is normal for things to change in medicine, for dogma to be contradicted by a new finding, and for a new way of treatment to render another incorrect. However, this usually happens over years, and we have time to nurse our old folly and coddle our new wisdom. Now, with our knowledge of SARS changing daily, we have no time to lull ourselves into any illusion of understanding. The staff in the emergency department all follow the daily number of cases, the number of fatalities. It is like watching flood water rise at a dike, and wondering if it will overflow.

I and a fellow physician were deciding how to manage a patient who was struggling to breathe. We decided to isolate the patient and treat him as a suspected SARS case even though he did not meet the criteria in the flow-chart of that day. Why did we do this? The situation of this patient who was struggling to breathe didn't quite make sense. It just 'didn't look right' to our 'clinical instinct', that sacred gut reaction of medicine. My colleague said,

"If we don't isolate him now, we may look back and think we were idiots."

What he meant is that if we missed one case because it didn't fit the guidelines, the potential consequences could be immense. Days after, the protocol was altered to accommodate the consideration of SARS in patients such as this who presented with apparently other respiratory problems in an 'atypical manner'. As a profession, we're still figuring it out.

In the lounge, there is mostly quiet, and the little talk is about SARS. At breaks, everyone drinks water. The masks cause a very dry mouth – it's like working in a hot fog. One of the nurses said one night,

"If I thought that coming to work I could catch something that could kill me, I wouldn't come to work."

This thought has crossed many of our minds, of course. We hope that none of us will contract SARS or die from it, and I know of no one who has stopped coming to work out of fear. I keep on thinking that this is what health care has always been like, that in the past few decades we in North America have been briefly sheltered from humanity's long history of plagues, epidemics, and deadly scourges. It makes me think that maybe we've had a bit of a honeymoon, that perhaps now we're getting a little taste of the real marriage between humanity and infectious disease.

Early in the outbreak, I advised a woman that she would need to be admitted to hospital for emergency surgery to treat a life-threatening problem. She agreed but asked me anxiously,

"Tell me the truth, do you have SARS in this hospital?"

At that time, my answer was that we did not. The patient was very relieved, despite her other medical problems. Now, my answer would be different. We now have SARS patients who have come through our emergency department and are admitted to our hospital. For the moment, our clinics remain closed, and in the emergency department we try to be vigilant for SARS, care for all of our patients through our mask and gown barriers, and protect ourselves.

The masks, in addition to making it difficult to understand speech, impair much other communication. My conversations with patients seem distant and impoverished when I cannot see a grimace, or the understanding of a grin. These expressions contain many unspoken clues to diagnosis, as well as a sense of a person's human situation. My patients seem in danger of becoming random garbled speech emanating from a blue mask perched on top of a body. I must seem equally surreal, as a doctor floating through the room in my gown, waving my white-gloved hands. I find myself gesturing more, using a sort of mime to transmit the meanings that usually find themselves in my face.

For the moment, we in the hospitals continue to watch the flood of new cases, of daily news reports, and of the strange changes in our workplace filling our dike. We hope that this flood will not overflow into the community around us. It is a pleasurable freedom to leave work, to be able to breathe, to sit in a restaurant and understand what people are talking about. The number of new SARS cases seems to be slowing. It's too early to say what will happen, but hopefully it will burn itself out and leave us with a new appreciation of being able to see each other's faces. If not, we will continue to learn about SARS and about ourselves.